Healthcare Provider Details

I. General information

NPI: 1588636450
Provider Name (Legal Business Name): NAGARAKERE SHANKARAIAH MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 S CONGRESS AVE STE A
PALM SPRINGS FL
33461
US

IV. Provider business mailing address

3112 S CONGRESS AVE STE A
PALM SPRINGS FL
33461
US

V. Phone/Fax

Practice location:
  • Phone: 561-964-0110
  • Fax: 561-964-0401
Mailing address:
  • Phone: 561-964-0110
  • Fax: 561-964-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME57808
License Number StateFL

VIII. Authorized Official

Name: NAGARAKERE SHANKARAIAH
Title or Position: ADMINISTRATOR
Credential: MD
Phone: 561-964-0110